Mark M. Connolly

Bowel Obstruction in Pregnancy

Intestinal obstruction during pregnancy and in the puerperium is an uncommon complication, although cases are probably underreported. Fortunately, the mortality rate has improved over the decades. Overall, it was greater than 60% in 1900. By the 1930s, maternal mortality had dropped to 21% and fetal mortality decreased to 50%. Modern rates of maternal mortality have shown continued improvement, with Goldthorp reporting an incidence of 12% in 1966. Over the last 30 years the maternal mortality rate has decreased to approximately 6%, as noted in various series published in the English literature. Fetal mortality rates, however, have remained significantly high. They have remained constant at between 20% and 26%. Furthermore, only one third of patients with prenatal bowel obstruction complete term pregnancies after operative resolution of their obstruction. These findings emphasize the importance of remembering that two patients are at risk when intestinal obstruction complicates pregnancy. The delay from presentation to admission and from admission to definitive management continues to be a significant cause of morbidity and mortality. A high index of suspicion is mandated in this patient population, especially in those women presenting with a history of previous abdominal or pelvic surgery. The high incidence of necrotic bowel found in this subset of patients demonstrates the need for aggressive surgical intervention. Only through diligent and urgent intervention can the morbidity and mortality be decreased. The diagnosis and treatment of a pregnant patient suspected of having a bowel obstruction should be no different from those given to a nonpregnant one.

Carcinosarcoma of the esophagus--pattern of recurrence.

Carcinosarcoma of the esophagus is a rare malignant neoplasm, predominantly affecting men in their seventh decade of life. While presenting symptoms and anatomic location of squamous cell and carcinosarcoma of the esophagus are similar, the latter often presents as a large intraluminal polypoid mass on barium esophagram. The more favorable prognosis associated with carcinosarcoma versus other esophageal neoplasms has been attributed to early onset of symptoms, resulting in prompt diagnosis, and a lower propensity for tumor invasion. We report the case of an elderly woman presenting with dysphagia who was initially diagnosed with esophageal leiyomyosarcoma. Final tumor pathology showed esophageal carcinosarcoma.

Unusual Metastatic Patterns of Invasive Lobular Carcinoma of the Breast

Invasive lobular carcinoma of the breast has similar patterns of metastatic disease when compared to invasive ductal carcinoma; however, lobular carcinoma metastasizes to unusual sites more frequently. We present a 65-year-old female with a history of invasive lobular breast carcinoma (T3N3M0) treated with modified radical mastectomy and aromatase-inhibitor therapy who underwent a surveillance PET scan, which showed possible sigmoid cancer. Colonoscopy with biopsy revealed a 3 cm sigmoid adenocarcinoma. The patient underwent a lower anterior resection. Pathology showed an ulcerated, invasive moderately differentiated adenocarcinoma extending into but not through the muscularis propria. However, six of seventeen paracolonic lymph nodes were positive for metastatic breast carcinoma (ER+/PR+), consistent with her lobular primary breast carcinoma; there was no evidence of metastatic colon cancer. This case highlights the unusual metastatic patterns of lobular carcinoma.

Case study: reduction of gluteal implant infection rates with use of retention sutures.

Summary: The intramuscular technique has been the most popular technique among plastic surgeons for gluteal implantation. Complication rates of up to 30% including infection, hematoma, seromas, and dehiscence are reported in several studies. One main question that arises is whether the wound dehiscence occurs first followed by infection or vice versa. We present a case study of 3 patients who received gluteal augmentation. We used an alternative technique in closure of the gluteal flap which included the use of retention sutures along the sacral incision. Follow-up included postoperative day 2, every week for 6 weeks, and then every month for 6 months. Postoperatively patients were advised to not sleep in supine position for 3 weeks and avoid pressure to the area. The 3 patients remained infection free at 2 days and weekly for 6 weeks. The use of retention sutures along the flap closure site may be a useful and simple technique to avoid high gluteal implant infection rates that have been reported in the literature. We plan to apply this technique to all of our future gluteal augmentations and track long-term results. Preventing complications will result in improved aesthetic results, increased patient satisfaction, less frequent office visits, and less financial cost to both patient and physician.

Consensus Statement on Mandatory Registration of Clinical Trials

ventions and research hypotheses, and basic methodology [2, 4] . The SJEG member journals will require registration of all prospective clinical trials as of July 1, 2007. Trials that begin after July 1, 2007 must register before enrollment of the first study subject, and trials that began before the deadline must register prior to editorial review. Submitted manuscripts must include the unique registration number in the abstract as evidence of registration. Authors submitting manuscripts reporting on unregistered clinical trials may request consideration of their papers if they can provide sufficient evidence of merit, although we anticipate that all clinical trials will be registered after July 1, 2007. The member journals of the Surgery Journal Editors Group (SJEG), in keeping with their commitment to high ethical standards and integrity in surgical publishing and surgical science, agree to adopt the position of the International Committee of Medical Journal Editors (ICMJE) [1, 2] requiring mandatory registration of all clinical trials, whether publicly-funded or commercially-sponsored, as a condition of consideration for publication. Additionally, the SJEG will require registration of Phase I and Phase II trials. Specifically, the SJEG supports the idea of promoting a publicly accessible clinical trial database as suggested by the World Health Organization (WHO) International Clinical Trials Registry Platform established in August 2005, which specifies 20 key study data reporting requirements [2] . The goal of the WHO initiative and this SJEG requirement, based on the ICMJE statement, is to promote transparency and honesty in reporting prospective clinical trial conduct and results (including negative results), to foster public trust, and to ensure that researchers behave in an ethically responsible manner toward patients and study participants [3] . The SJEG member journals will require all clinical trials that prospectively assign human subjects to medical interventions, comparison groups, or control groups for the purpose of examining the potential health effects of such interventions, to be registered in one of several free, publicly accessible, nonprofit electronically searchable databases such as the one administered by the National Library of Medicine (NLM), which is located at http://www.clinicaltrials.gov. The ICMJE defines medical interventions as those that include, among other things, drugs, surgical procedures, devices, behavioral treatments, and process-of-care changes [2] . The required minimal registration data set includes a unique trial number established by the registry, funding source(s), primary researcher and public contact person, ethics committee approval, trial recruitment information, interPublished online: March 27, 2007